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Laparoscopic Cholecystectomy
Dr. Brunicardi Key Materials Laparoscopy Kit 10 mm 30 deg scope 5 mm 30 deg scope Operative Steps 1. Vertical incision through umb: Start in middle, saw down with 11 blade, then back up. 2. Using scissors, cut umbilical stalk - careful to not cut fascia or skin 3. Dilate umbilical ring with kelly clamp 4. Nick inferior edge with 11 blade 2-3 mm (optional if tight) 5. Place 10 mm trocar w/ balloon 6. Inflate balloon, start insufflation to 15 mm Hg 7. Trocars: place sheath first by palming in R hand, hold at abd with L hand. Twist while hold tension, adjust angle once peritoneum is tented. 8. Insert 10mm 30 degree scope 9. Place 5 mm trocar sheath w/ metal tip -> followed by 5 mm trocar below xiphoid, slightly right of midline 10. Place 5 mm trocar as far lateral to sub-xiphoid trocar 11. Place 5 mm trocar at level of umb, slightly right of mid-clavicular line 12. Using (?name) grasper, restract GB cranially and grasp neck of GB 13. Using kittner, bluntly dissect overlying fat/omentum from gallbladder until GB, cystic/common duct come into view 14. Using “twirling” motion adjacent to cystic duct near neck of GB, clean duct with kittner 15. Using marilyn grasper, dissect and clean cystic duct 16. Place two clips towards patient, one clip towards GB, cut. Load clip intra-abd (by squeezing handle lightly), clip, pull back, re-load, push in again. 17. Using kittner/marilyn, dissect cystic artery 18. Clip twice towards patient, one clip towards GB, cut 19. Search carefully for posterior branch of cystic artery 19. Using cautery attached to suction-irrigator, alternate suction to remove smoke 20. Remove GB from fossa 21. Place in endoclose bag, do not clamp string 22. Examine staple line, infra-hepatic fossa, pelvis, suction fluid 23. Remove umb trocar with specimen, replace trocar 24. Remove trocars under direct vision 25. Terminate insufflation, remove umb trocar 26. Need: S retractor, vascular pickups, clamps. Close umb ring with 0 vicryl suture on CT needle with interrupted sutures, clamp, sweep with finger to check caught bowel/omentum, tie (8 knots)/cut at the end. 27. Close umbilical skin with 4-0 monocryl, buried interrupted sutures 28. Close remaining ports of 4-0 monocryl, buried interrupted sutures Dr. Chen Key Materials Laparoscopy kit with 10 mm zero degree scope, 5 mm(?) 30 degree scope Operative Steps 1. Place 5 mm transverse incision to the left of the umbilicus 2. Using zero degree 10 mm scope attached to visual trocar, insert trocar under vision 3. Keep downward pressure with camera, spin trocar 180 degrees 4. Go through anterior rectus sheath, rectus, post sheath, watch color change white -> yellow (peritoneum to omentum) 5. Drop angle, slide in trocar. Remove scope, change to 30 degree scope. 6. Attach gas, insufflate to 15 mmHg 7. Place 11 mm trocar 2 finger breadths below xiphoid 8. Place 5 mm trocar in RUQ, more laterally RLQ (anatomic location?) 9. Grasp GB, retract crainally 10. Bluntly sweep away small bowel 11. Attach cautery to marilyn 12. Grasp peritoneum overlying cystic duct, pull out and away (towards camera), buzz, pull out and down. Don’t rip tissue uncauterized tissue. 13. Turn tips towards duct, dissect out duct. (Close tips -> push in -> spread -> out w/o closing) 14. Grasp free edges of peritoneum dissected away from duct, buzz, pull away 15. Turn tips away from cystic artery, dissect out artery 16. Confirm critical view 17. Using medium clips, get around duct/artery, push in, fire two clips towards patient, one clip toward GB 18. (Optional) if duct is large/unsure if you clipped all the way. Use endo-loop: place at 6 o’clock position at cut proximal stump of cystic duct. Break plastic, cinch loop below staple line. Cut. 19. Attach cautery to spatula-suction/irrigator 20. Remove GB from fossa by “using spatula like a pen, and you’re drawing the line between GB and liver (towards GB).” NEVER stop buzzing, keep sweeping left and right. Target areas of greatest tension. 21. Place GB in endo-catch 22. Remove specimen. Replace 11 mm trocar. 23. Inspect GB fossa, clipped stumps for hemostasis 24. Suction over liver, pelvis 25. Remove trocars under direct vision: 11mm, RUQ, RLQ. For umbilical trocar, pull back trocar, keeping camera in place. Then slowly pull back camera. 26. Close 11 mm with S retractors, kochers on fascia, prolene on UR needle (size? 2-0?), do a figure of eight stitch. 27. Close remainder with buried interrupted sutures using 4-0 monocryl